1326225632 NPI number — CENTRO DE SALUD DE LA COMUNIDAD DE SAN YSIDRO INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326225632 NPI number — CENTRO DE SALUD DE LA COMUNIDAD DE SAN YSIDRO INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CENTRO DE SALUD DE LA COMUNIDAD DE SAN YSIDRO INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
SAN YSIDRO HEALTH CHC-OCEAN VIEW
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1326225632
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/06/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1601 PRECISION PARK LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN DIEGO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92173-1345
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
619-662-4100
Provider Business Mailing Address Fax Number:
619-428-7952

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3177 OCEAN VIEW BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92113-1432
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-662-4100
Provider Business Practice Location Address Fax Number:
619-428-7952
Provider Enumeration Date:
01/29/2008

Additional Information

Authorized Official

Authorized Official Last Name:
MATTSON
Authorized Official First Name:
KEVIN
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT/CEO
Authorized Official Telephone Number:
619-662-4100

Provider Taxonomy Codes

  • Taxonomy code: 261QF0400X , with the licence number:  090000143 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: W5740 . This is a "MEDICARE PART B PTAN" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: FHC11998G , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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